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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Discover people-centred decision-making for pharmacists in this clear and practical volume
Pharmacy ethics and decision-making are a critical part of pharmaceutical care. Pharmacists are routinely faced with decisions that impact the immediate and long-term health of patients, and must exercise professional judgement when the best choices are uncertain.
Current guides to ethical decision-making in healthcare are generally written for doctors or nurses, overlooking the distinctive needs of pharmacy professionals in this crucial area of practice.
People-Centred Pharmacy: Ethical Challenges in Everyday Practice remedies this oversight with a down-to-earth discussion of the common ethical dilemmas pharmacists face. Offering a commonsense focus, the book articulates an approach to practical ethical reasoning that considers the interests of all involved, including the pharmacist. The result is an invaluable resource for pharmacists and those studying the subject.
Readers will also find:
- A text written in collaboration with pharmacy educators
- Concrete examples drawn from empirical research into pharmacy practice
- An interdisciplinary approach to the many dilemmas pharmacists face
People-Centred Pharmacy: Ethical Challenges in Everyday Practice is ideal for all pharmacy staff, as well as all students of pharmacy.
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Seitenzahl: 358
Veröffentlichungsjahr: 2025
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
Dedication
Also by David Seedhouse
Foreword
Acknowledgements
What to Expect from This Book
REFERENCE
Introduction
SAFE CARE, LAW AND ETHICS
WHEN PEOPLE‐CENTRED CARE IS ESSENTIAL
REFERENCES
What Is a Person?
FROM PERSON‐CENTRED PHARMACY TO PEOPLE‐CENTRED PHARMACY
THE TRADITIONAL VIEW: DISPASSIONATE PROFESSIONAL DELIVERS CARE OBJECTIVELY HE OR SHE IS NEITHER PERSONALLY INVOLVED NOR AFFECTED HE OR SHE WILL ATTEMPT TO MEET ONE INDIVIDUAL’S NEEDS WHATEVER HE THINKS OF THAT INDIVIDUAL’S CHOICES
IN PEOPLE‐CENTRED PHARMACY THE PHARMACIST IS NOT DETACHED
THE MOVE TO PEOPLE‐CENTRED CARE
HEALTHCARE ALWAYS INVOLVES AT LEAST TWO PERSONS
PRU AND ABDUL ARE DIFFERENT PERSONS
BENJAMIN IS A PERSON TOO
PERSONAL PROBLEM SOLVING
WHAT DOES PEOPLE‐CENTRED CARE MEAN FOR THE PHARMACIST?
REFERENCES
The DPN
THE CATEGORIES
THE CASES
CHAPTER 1: Category One: Should I Supply?
DISCUSSION
DISCUSSION
SO, WHAT'S THE RIGHT ANSWER?
DPN RESULTS
HOW DOES THIS KNOWLEDGE HELP THE PHARMACIST?
THE NEED FOR VALUE JUDGEMENTS WHEN THE RULES ARE NOT ENOUGH
DISCUSSION
DISCUSSION
REFERENCES
CHAPTER 2: Category Two: Patient Choice
DPN RESULTS
DISCUSSION
DISCUSSION
DISCUSSION
DPN RESULTS
DISCUSSION
DISCUSSION
DISCUSSION
REFERENCES
CHAPTER 3: Category Three: Best Interests of the Patient or the Business?
DISCUSSION
DISCUSSION
DISCUSSION
DISCUSSION
REFERENCES
CHAPTER 4: Category Four: Confidentiality
DISCUSSION
DISCUSSION
DPN RESULTS
DISCUSSION
DISCUSSION
DISCUSSION
DISCUSSION
REFERENCES
CHAPTER 5: Category Five: Individual or Family Decision?
DISCUSSION
DISCUSSION
USING THE DPN
DISCUSSION
USING THE DPN
DISCUSSION
REFERENCES
CHAPTER 6: Category Six: Cultural Diversity
DISCUSSION
DISCUSSION
FINDINGS OVER TIME
DISCUSSION
NO MAN IS AN ISLAND?
WHY DOES THIS MATTER TO THE PHARMACIST?
REFERENCES
CHAPTER 7: Category Seven: Third‐Party Request
DISCUSSION
DISCUSSION
DPN RESULTS
DISCUSSION
DISCUSSION
DPN RESULT
DISCUSSION
REFERENCES
CHAPTER 8: Category Eight: The Scope of My Professional Role
DISCUSSION
DISCUSSION
REFERENCES
CHAPTER 9: Category Nine: Compliance
DPN Results
DISCUSSION
DPN RESULTS
DISCUSSION
DISCUSSION
REFERENCES
CHAPTER 10: Category Ten: Personal Values
DPN RESULT
DISCUSSION
DISCUSSION
DISCUSSION
REFERENCES
CHAPTER 11: Category Eleven: Public Health
DPN RESULTS
DISCUSSION
DISCUSSION
DPN RESULTS
DISCUSSION
REFERENCES
CHAPTER 12: Category Twelve: Professional Relationships
DISCUSSION
DISCUSSION
REFERENCES
Healthcare Ethics as a Decision‐Making Tool
TWO BASIC QUESTIONS
WORK FOR HEALTH IS MUCH MORE THAN WORK AGAINST DISEASE AND ILLNESS
HOW THE HEALTH AS A STAGE APPROACH MIGHT BE USED
BRIEF ANALYSIS USING HEALTH AS A STAGE
HOW THE HEALTH AS A STAGE APPROACH PLUS THE ETHICAL GRID MIGHT BE USED
A POSSIBLE APPLICATION OF THE GRID IN THIS CASE
REFERENCES
Conclusion: Using Personal Judgement as a Pharmacy Professional
REFERENCES
Postscript: Ethical Challenges Will Shape the Future of Pharmacy
REFERENCE
Index
End User License Agreement
List of Tables
Healthcare Ethics as a Decision-Making Tool
TABLE 1 The foundations with more specific content.
List of Illustrations
What Is a Person?
FIGURE 0.1 Some influences that create persons.
FIGURE 0.2 Healthcare requires interaction between persons.
Chapter 1
FIGURE 1.1 The prescription.
FIGURE 1.2 Prescription guidance.
FIGURE 1.3 Screenshot of a values snapshot survey on the DPN.
FIGURE 1.4 DPN results.
FIGURE 1.5 Value judgements.
FIGURE 1.6 DPN result.
FIGURE 1.7 DPN results.
Chapter 2
FIGURE 2.1 DPN results.
FIGURE 2.2 Value trends.
FIGURE 2.3 DPN and values result (16 respondents).
FIGURE 2.4 DPN and values result (25 respondents).
FIGURE 2.5 DPN results.
Chapter 4
FIGURE 4.1 DPN result.
FIGURE 4.2 DPN results.
FIGURE 4.3 DPN results.
Chapter 5
FIGURE 5.1 DPN results.
FIGURE 5.2 Concept details.
FIGURE 5.3 DPN results.
FIGURE 5.4 DPN results.
Chapter 6
FIGURE 6.1 DPN results.
FIGURE 6.2 Concept details.
FIGURE 6.3 If you cannot see the boxes, you cannot understand the bubble.
FIGURE 6.4 A Western ethics committee rational field.
FIGURE 6.5 Kyrgyz consent decision‐making rational field.
FIGURE 6.6 An individualistic rational field.
Chapter 7
FIGURE 7.1 DPN results and values trends.
FIGURE 7.2 DPN results and values trends.
Chapter 9
FIGURE 9.1 DPN results: cohort of 273.
FIGURE 9.2 DPN results: cohort of 70.
FIGURE 9.3 Values trends.
FIGURE 9.4 ‘Safety’ values trend in both cohorts.
FIGURE 9.5 DPN results.
FIGURE 9.6 Values trends.
Chapter 10
FIGURE 10.1 DPN results.
Chapter 11
FIGURE 11.1 DPN results.
FIGURE 11.2 DPN results and values trends.
Healthcare Ethics as a Decision-Making Tool
FIGURE 1 The stage and the player or players, representing health.
FIGURE 2 DPN results.
FIGURE 3 Values trends.
FIGURE 4 A section of the ethical grid.
FIGURE 5 Expanding the grid.
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
Dedication
Also by David Seedhouse
Foreword
Acknowledgements
What to Expect from This Book
Introduction
What Is a Person?
The DPN
Begin Reading
Healthcare Ethics as a Decision‐Making Tool
Conclusion: Using Personal Judgement as a Pharmacy Professional
Postscript: Ethical Challenges Will Shape the Future of Pharmacy
Index
Wiley End User License Agreement
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People‐Centred Pharmacy
Ethical Challenges in Everyday Practice
David Seedhouse
Aston Pharmacy School, Birmingham, UK
With contributions from
Sima Hassan and national and international pharmacy colleagues
This edition first published 2025© 2025 John Wiley & Sons Ltd
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Library of Congress Cataloging‐in‐Publication Data Applied for:Paperback ISBN: 9781394218776
Cover Design: WileyCover Image: © Digital Storm/Shutterstock
Dedication
To the many thousands of pharmacy students who respond so thoughtfully to the practical challenges posed by everyday ethical dilemmas.
Also by David Seedhouse
Health: The Foundations for Achievement, 1986, 2001 (Wiley)
Ethics: The Heart of Health Care, 1988, 1998, 2009 (Wiley)
Changing Ideas in Health Care (edited, with Alan Cribb), 1989 (Wiley)
Liberating Medicine, 1991 (Wiley)
Practical Medical Ethics (with Lisetta Lovett), 1992 (Wiley)
Fortress NHS: A Philosophical Review of the National Health Service, 1994 (Wiley)
Reforming Health Care: The Philosophy and Practice of International Health Reform (edited), 1995 (Wiley)
Health Promotion: Philosophy, Prejudice and Practice, 1997, 2003 (Wiley)
Practical Nursing Philosophy: The Universal Ethical Code, 2000 (Wiley)
Total Health Promotion: Mental Health, Rational Fields and the Quest for Autonomy, 2002 (Wiley)
Values Based Decision‐Making for the Caring Professions, 2006 (Wiley)
Thoughtful Health Care, 2017 (Sage)
Using Personal Judgement in Nursing and Healthcare (with Vanessa Peutherer), 2020 (Sage)
The Case for Democracy in the Covid 19 Pandemic, 2020 (Sage)
Foreword
‘If computers could do this, you wouldn't be needed.’
I first said this to a group of pharmacy students nearly 25 years ago. It was around the time that to ‘google’ something was becoming embedded as part of everyday life, and starting its role as a verb in everyday speech. I hope this statement of fact was taken as it was intended. Not as a foretelling of the demise of their chosen profession, but as an encouragement to reflect on the challenges they would face as an integral part of their future professional role.
Twenty‐five years later, the contexts may have changed but the principle is still the same. Our software support and expert systems are so much more sophisticated now, and our access to essential information has improved almost out of recognition. However, the ready availability of robust information from reputable sources is only part of what is needed when pharmacy professionals make decisions about patient care in practice.
In case we think there is an easy solution around the corner, AI is not the answer. There is huge potential for it to contribute to healthcare by analysing data far beyond the capabilities of humans, but it is not ready for real‐life decision‐making in patient care. Context is everything in these situations and the ability of humans to empathise and feel compassion for others cannot be replicated by AI systems. It is essential that the healthcare professional can see the situation through the eyes of the patient. The ability to see through different lenses and appreciate those different perspectives is central to understanding, and empathising with, the patient's needs. True empathy can be mimicked, perhaps, but not replicated. In the context of our question, ‘can a computer replace the pharmacy professional?’, unless an AI system develops dispositional rather than (programmed or inferred) situational empathy then its contribution to decision‐making in healthcare will be limited to the technical challenges.
That 25‐year development in technology from my first ‘if computers could do it’ sits within a much longer, profound transition in the roles of pharmacy professionals. The longstanding medicines supply role, and before that the compounding role, developed into much wider advisory roles, for patients and prescribers. The profession moved from gatekeeping dosage errors and interactions to proactive medicines use improvements, and at the same time became much more integrated with other healthcare professionals and teams. The list of medicines available for pharmacists to supply without prescription has expanded greatly, and with that the professional responsibility for those supplies. The handful of pharmacist prescribers 20 years ago has grown to around 16 000 at the time of writing, and the profession is moving rapidly towards every newly registered pharmacist having an independent prescribing qualification. Every one of those changes has added to the complexity of decisions in practice.
In parallel with these changes, the importance of patient‐, or person‐, centredness has emerged as a key tenet of good healthcare more widely. This has been marked by a profound shift from a ‘Dr knows best’ paternalism to striving for concordant ‘person‐centred’ treatment decisions. That focus on the individual at the centre of a decision has been very influential in our approach to healthcare, especially in healthcare education where it has allowed us properly to balance technical aspects of care with the needs of the individual. However, no decision affects only one individual. In healthcare there may be an effect on the decision‐maker, or other people close to the patient such as carers and family, or on people remote from the patient such as those who might be denied treatment in a resource‐constrained NHS. In practice we must consider ‘people’ as well as the ‘person’.
With all the advances in technology, widening of roles, and evolution of healthcare practice, pharmacists are asked to make ever more difficult decisions. If these decisions were abstract, albeit complicated, technical questions then often there would be a clear right response. However, the most complex elements in any decision are the people it involves – people with preferences, needs, biases and experiences that will be different for every individual.
My students of 25 years ago, and students now, would be delighted if judgements were straightforward and readily accessible. Pharmacy professionals faced with dilemmas in practice will feel the same. Making sometimes difficult judgements is what we are there for, but it does not mean that making those decisions is without its stresses through feelings of uncertainty and the weight of responsibility.
What this book provides is a training ground to develop and hone these decision‐making skills. Whether for student pharmacists or practitioners, the case studies and supporting narratives allow complex decisions to be rehearsed. This may be by individual reflection, in discussion with workplace colleagues or in the classroom. It also, exceptionally rarely for works of this type, places the decision‐maker squarely within the decision‐making process, acknowledging that the toughest decisions in practice will be people‐centred.
Mark Brennan, Pharmacist registered with the GeneralPharmaceutical Council, LLM, BSc, PgCTLDeputy Head of Aston Pharmacy SchoolReader in Healthcare Ethics and LawCollege of Health and Life SciencesAston UniversityUK
Acknowledgements
I am responsible for the original idea for this book, the theoretical background, and the presentation of the material. Much of this is based on my previously published work in ethics and decision‐making.
I have been fortunate to work with colleagues in a School of Pharmacy for the last five years and have learnt a great deal about the day‐to‐day challenges that pharmacists face. I hope that by combining my philosophy of health and ethics with dilemmas of pharmacy practice this book can make a useful contribution to safe, effective and thoughtful practice.
I acknowledge the contributions of several colleagues over many years, in particular Mark Brennan and in the present context Sima Hassan, I have gleaned much about the reality of everyday practice from both. I am also grateful to Vanessa Peutherer, Maria Allinson, Michelle Bowden, Fiona Kelly, Amanda Lees, Rosemary Godbold, Sarah Sivers and Thorsten Lauterbach. Each has helped ensure the authenticity of the cases and the accuracy of any technical details, and most have provided clinical dilemmas specifically for this book.
I would particularly like to thank the many thousands of under‐ and post‐graduate students and practitioners who have responded to scenarios on the Deliberative Practice Network (DPN). Without them this book would lack the rich qualitative insights of actual pharmacist narratives and thought processes, while the vast quantitative data collected as a result of their engagement has added reliability and validity to this unique project.
I use the personal pronoun ‘we’ for convenience of communication in various parts of the book. Many of the cases have been developed and/or used by different teachers and researchers. Most of them have been presented on the software system (the DPN) I designed and built. The DPN results presented in various parts of the book are from a range of teaching situations involving thousands of different students and practitioners. ‘We’ in this sense refers to a collective effort to foster the most thoughtful healthcare.
Inevitably, different individual teachers will have their own opinions about the various cases. However, we all believe in the value of deliberative practice in healthcare.
I initiated and have overseen this project; therefore, I take full responsibility for any errors, omissions, misunderstandings and oversights.
I use ‘I’ to indicate those parts of the book based on my personal theoretical work.
David Seedhouse
What to Expect from This Book
This book provides theoretical and practical guidance to pharmacists who wish to deliver the best healthcare in complex circumstances.
There are many books dedicated to medical and nursing decision‐making, but few solely for pharmacists. It is possible to adapt parts of other professions' texts to a pharmacy environment, however today's changing pharmacy landscape merits a decision‐making guide of its own, grounded in examples from everyday practice.
We teach decision‐making to pharmacy undergraduates and qualified pharmacists, using real‐life dilemmas to improve students' decision‐making capabilities. We encourage discussion of all relevant factors, including science, legislation, values, ethics, personhood and social contexts.
When teaching, we loosely categorise our discussion cases to help students organise their thoughts. We use a similar system in this handbook, offering 12 categories and 50 practical examples which reflect the pharmacist's diverse modern role, including independent prescribing [1].
People‐centred pharmacy does not provide clear cut answers to decision‐making dilemmas in pharmacy, rather it presents controversial situations for reflection and discussion. By using it the pharmacist will:
learn how to use deliberative practice to achieve and justify practical ends;
recognise the theoretical and practical limitations of codes and standards;
appreciate the extent to which different people – both patient and professional – can have conflicting values;
develop and practise ways of making the best decisions where values differ.
In short, studying this book will help develop and maintain thinking skills essential to competent practice in today's fast‐changing environment. As a pharmacist, if you find yourself in a social situation where the best course of action is unclear, turn to the most relevant categories and reflect on how their examples relate to your own dilemma.
REFERENCE
1. BBC News (31 January, 2024). Seven conditions that your local chemist can now treat.
https://www.bbc.co.uk/news/health‐68139870
(accessed 25 September, 2024).
Introduction
The pharmacy profession is rapidly evolving from a predominantly technical, science‐based discipline into a patient‐focused service able to carry responsibilities previously assigned to primary care doctors, including independent prescribing [1].
This evolution is reflected in the nine standards the General Pharmaceutical Council (GPhC) expects pharmacists to demonstrate. The Council states that pharmacy professionals must:
‘provide person‐centred care
work in partnership with others
communicate effectively
maintain, develop and use their professional knowledge and skills
use professional judgement
behave in a professional manner
respect and maintain the person's confidentiality and privacy
speak up when they have concerns or when things go wrong
demonstrate leadership.’
[2]
Apart from Standard 4, each of these principles requires knowledge and skills beyond clinical expertise.
Because the standards are rarely examined in depth in the traditional pharmacy curriculum, we have collated a comprehensive set of examples under key headings to enable pharmacists to practise interpreting them in realistic situations. We initially chose ‘person‐centred care’ as our theoretical framework, since this is the GPhC's first Standard:
‘Every person is an individual with their own values, needs and concerns. Person‐centred care is delivered when pharmacy professionals understand what is important to the individual and then adapt the care to meet their needs – making the care of the person their first priority.’[2]
Other health professions have similar criteria. The General Medical Council (GMC), for example, says doctors should:
‘Treat patients as individuals and respect their dignity, respect patients' right to confidentiality, work in partnership with patients, respecting their right to reach decisions with doctors about their treatment and care, and work with colleagues in ways that best serve patients' interests.’ [3] (Guidance shortened.)
The Nursing and Midwifery Council (NMC) maintains that:
‘Being person‐centred means thinking about what makes each person unique, and doing everything you can to put their needs first.’ [4]
The official emphasis is firmly on the person. However, as the cases in this book demonstrate, there is more to best practice in pharmacy – and healthcare in general – than an exclusive focus on isolated individuals.
The GPhC's Standard 5 recognises this explicitly:
‘Pharmacy professionals must use their professional judgement
People expect pharmacy professionals to use their professional judgement so that they deliver safe and effective care. Professional judgement may include balancing the needs of individuals with the needs of society as a whole. It can also include managing complex legal and professional responsibilities and working with the person to understand and decide together what the right thing is for them – particularly if those responsibilities appear to conflict.’ [2]
SAFE CARE, LAW AND ETHICS
The Oxford Centre for Evidence‐Based Medicine lists harms and errors relating to medicines in the UK:
‘Numbers of patients affected by adverse drug reactions
Accident & emergency visits, 2.5%
Hospital admissions, 6.5%
Inpatients, 15%
Primary care visits, 25%
Reported rates of medication errors
Prescribing error rate in hospitals, 7% of prescription items
Prescribing errors rate in general practice, 5% of prescriptions of which 0.18% were severe errors; this implies 1.8 million serious prescribing errors each year
Dispensing error rate in hospitals, 0.02–2.7% of dispensed medicines
Dispensing error rates in community pharmacies, 0.01–3.32% dispensed medicines
Medicine administration errors in hospital, 3–8%.’
[5]
These sobering statistics show how important it is for pharmacists to be clinically and scientifically vigilant. They should be at the forefront of every pharmacist's mind. However, as the cases in this book show, they are by no means the whole story of contemporary pharmacy decision‐making.
Many of the book's examples raise issues of law. However, legislation is not discussed in depth since it is more than adequately covered elsewhere; for example, in [6] and [7]. These texts offer comprehensive accounts of the law relating to pharmacy. They are reference books all pharmacists should have at hand.
Other useful textbooks discuss cases and legal principles in the wider healthcare setting:
Principles of Medical Law, 4th edition, edited by Judith Laing and Jean McHale, Oxford University Press, 2017.
Medical Law, Text, Cases and Materials, 5th edition, by Emily Jackson, Oxford University Press, 2019.
Medical Law and Ethics, 8th edition, by Jonathan Herring, Oxford University Press, 2020.
Law is an essential consideration, but it is not always definitive. Where there is ethical uncertainty, insufficient guidance or conflicting legal rules, the pharmacist must use their professional judgement to decide.
Ethical insight is essential to the best human decision‐making. There is growing interest in its role in pharmacy, though the evidence base is currently smaller than that of other health disciplines:
‘Empirical ethics research is increasingly valued in bioethics and healthcare more generally, but there remain as yet under‐researched areas such as pharmacy, despite the increasingly visible attempts by the profession to embrace additional roles beyond the supply of medicines …’. [8]
From the research data that do exist, it is clear that most pharmacists are aware of ethical issues but rarely if ever use official codes and standards to deal with them:
‘… although most of the pharmacists were not conversant with the details of the Royal Pharmaceutical Society's Code of Ethics the examples of ethical dilemmas quoted could be classified and interpreted to demonstrate a knowledge of the basic ethical concepts and the wider legal, occupational, organisational and personal value sets which encompass ethics in the work place. Ethical dilemmas arose as a result of the pharmacist's role as supplier of prescription medicines, guardian of over‐the‐counter medicines and intermediary between patient and carer/doctor. Other dilemmas were related to the legal framework surrounding medicines as well as the organisational, occupational and personal values of the pharmacist.’ [9]
Pharmacists want to support their patients, and use ‘commonsense’ to do so:
‘The majority of pharmacists interviewed in NSW Australia practised within a theoretical framework of “best interests of the patient.” Pharmacists experienced dilemmas in practice involving a number of ethical principles. Pharmacists relied on common sense to circumvent such dilemmas and never referred to their professional code of ethics. There appeared to be a general lack of training, and a varying perception of difficulty with decision making, regarding ethical dilemmas encountered, depending on issues such as legal requirements, personal opinions or financial demands.’ [10]
A study in Saudi Arabia found that:
‘45.7% (of 850 community pharmacists) often discuss ethical issues with their patients, while only 2.1% never discuss it. 40.6% often record the ethical concern whereas only 1.9% of them never do so. 31.5% reported that patients initiate ethical issues … Most perceived ethical problems were: being asked for hormonal contraception, dispensing a drug for unreported indication (69.2%), dispensing dose of medicine for a child that is outside the SNF limits (68.9%), unwanted professional behaviour about controlled drugs (66.6%), a colleague insisting on unethical behaviour (65.0%), a colleague has done something unethical for the first time (64.7%), suspecting that a child is being abused (63.3%) prescribing on private scripts for suspected medications of possible abuse (60.7%) and terminally ill patient asks for a diagnosis or prognosis (52.9%).’ [11]
Pharmacy is replete with ethical issues and decision‐making dilemmas yet, compared to other healthcare professions, there is relatively little investigation and debate. This is certain to change as pharmacy is recognised as a frontline healthcare profession.
WHEN PEOPLE‐CENTRED CARE IS ESSENTIAL
Although trying to do the very best for individual patients is a core principle of healthcare, any therapeutic relationship involves more than one person: at the very least the carer (pharmacist) and the cared for (patient), and often several people at once.
Taking this into account, while acknowledging the significance of person‐centred healthcare, I have extended the focus to people‐centred care.
People‐centred care is essential where:
the needs of more than one person must be considered;
families wish or need to be included in the decision‐making process;
cultural norms do not place the individual person centrally;
it is unclear if the individual person has decision‐making capacity, for example when he or she has fluctuating cognition;
there are issues of confidentiality;
children and young people are involved;
parents or guardians disagree about what is best for their child;
resources are limited;
a third party has made a request;
other concepts are equally or more important than person‐centredness – for example, safety is frequently considered to take priority in risky circumstances;
the patient is choosing unwisely;
the patient is noncompliant;
the pharmacist's values are different from the patient's – for example, in relation to emergency contraception or needle exchange schemes;
the pharmacy employer's business goals are not compatible with the best interests of the patient;
public health considerations are believed to outweigh individual patient choice.
We believe that the book's title, People‐centred Pharmacy, best reflects this complex reality.
REFERENCES
1. NHS Business Services Authority (n.d.). What can a pharmacist prescriber prescribe?
https://faq.nhsbsa.nhs.uk/knowledgebase/article/KA‐01426/en‐us
(accessed 25 September, 2024).
2. Standards and guidance for pharmacy professionals (n.d.).
https://www.pharmacyregulation.org/pharmacists/standards‐and‐guidance‐pharmacy‐professionals
(accessed 22 November, 2024).
3. General Medical Council (n.d.). Ethical guidance for doctors.
https://www.gmc‐uk.org/ethical‐guidance/ethical‐guidance‐for‐doctors/good‐medical‐practice/duties‐of‐a‐doctor
(accessed 22 November 2024).
4. The Nursing and Midwifery Council Person‐centred care (updated 17 December, 2020). Caring with confidence: The code in action.
https://www.nmc.org.uk/standards/code/code‐in‐action/person‐centred‐care/
(accessed 25 September, 2024).
5. Aronson, J.K. (10 May, 2017). Ten principles of good prescribing. Centre for Evidence‐Based Medicine.
https://www.cebm.ox.ac.uk/resources/top‐tips/ten‐principles‐of‐good‐prescribing
(accessed 25 September, 2024).
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What Is a Person?
People‐centred care is concerned with promoting the health of one or more persons, in the broadest sense of health. The key to understanding how best to deliver it is to identify what a ‘person’ is.
This is not at all straightforward. The elements that constitute ‘personhood’ are contested and there is no agreed definition.
‘A person (pl.: people or persons, depending on context) is a being who has certain capacities or attributes such as reason, morality, consciousness or self‐consciousness, and being a part of a culturally established form of social relations such as kinship, ownership of property, or legal responsibility. The defining features of personhood and, consequently, what makes a person count as a person, differ widely among cultures and contexts.’ [1]
It is commonly assumed that human beings are persons, but a little thought shows these concepts are not necessarily identical. Is a human being incapable of thought a person? Is a newborn baby a person? Was she a person one hour before her birth? Is an elderly woman with incapacitating dementia a person? If you cannot remember who you are or anything about your history, are you a person? Is a human being in a permanent coma a person?
‘Normally we use the term “person” as a synonym for “human beings,” people like us. However we are also familiar with the idea that there are nonhuman persons, and humans who are not, or may not be persons or full persons. Nonhuman persons may include gods, demigods, ghosts, extraterrestrials, angels and devils. They may also include animals, fictional and real … Human nonpersons or humans who are not fully fledged persons may include zygotes and embryos, or individuals who are “brain‐dead,” anencephalic infants, or individuals in persistent vegetative state.’ [2]
As is often the case, the science fiction series Star Trek, provides an accessible way to reflect on some of the possibilities:
‘Star Trek: Is Commander Data a Person?
consider an interesting thesis, advanced in an episode of Star Trek: The Next Generation (“The Measure of a Man”). In that episode one of the main characters, an android called “Commander Data,” is about to be removed from the Starship Enterprise to be dismantled and experimented upon. Data reuses to go, claiming to be a person with “rights” … He believes that it is immoral to experiment on him without his consent. His opponent, Commander Maddox, insists that Data is property, that he has no rights. A hearing is convened to settle the matter. During the trial, the attorneys consider …
What is a person?
Is it possible that a machine could be a person?
In the Star Trek episode, it is assumed that anything that is “sentient” should be granted the status of “personhood” and Commander Maddox suggests that being sentient requires that the following three conditions must be met:
Intelligence
Self‐awareness
Consciousness
Captain Picard, who is representing Commander Data … tries to convince the judge that Data possesses these properties (or at the least, that we are not justified in concluding that he lacks the properties).’ [3]
Of course, Picard’s argument begs equally challenging questions about the nature of intelligence, self‐awareness and consciousness – increasingly focused by developments in AI. But these are beyond the scope of this book.
Instead, I have taken a down‐to‐earth approach. I assume that Figure 0.1 represents the key influences that create persons – remove these one by one and the person fades like the smile of the Cheshire cat in Alice in Wonderland.
Each of these influences build what we call persons. As each influence changes, so does the person.
The ‘commonsense’ view of ourselves and others is that we are essentially unchanging – solid, persisting selves. But reflection on the elements in Figure 0.1 gives pause for thought.
Some of the influences are fixed, for example the rules of logic, human instincts, past decisions and personal history. Others, such as stress, knowledge, present circumstances and emotion change continually. In some ways we are the same people we were yesterday, and in other ways we are not. If I lose my job, or become ill, or am bullied, or am fearful, or inherit a fortune, I will still be me, but not exactly the same me I was the day before.
There is a fluidity about being a person that healthcare professionals should constantly bear in mind if they are to deliver the most thoughtful healthcare [4]. Both the professional and the patient are shifting beings, living in an environment in constant flux – a fact well‐known to Ancient Greek philosophers:
‘It is not possible to step twice into the same river according to Heraclitus, or to come into contact twice with a mortal being in the same state.’ [5]
Empirically, psychology shows that human beings are biased in well over 200 different ways [6]. These biases affect how we see the world and how we interact with it. Few if any of these are static either. For example, to varying degrees each of us is subject to the following.
FIGURE 0.1 Some influences that create persons.
Confirmation Bias: We favour information that conforms to our existing beliefs, and we discount evidence that doesn’t. For example, if we think climate change is responsible for increasing wildfires and hurricanes, we will focus on these events as proof; whereas if we take the opposite view, we will tend to seek out evidence that shows the frequency of these events is actually stable.
Availability Heuristic: We place greater value on information that comes to mind quickly than information that takes effort to research.
Halo Effect: Our overall impression of a person influences how we feel and think about their character. This especially applies to physical attractiveness, which strongly influences how we rate a person’s other qualities:
‘People who are sociable or kind, for example, may also be seen as more likable and intelligent. The halo effect makes it so that perceptions of one quality lead to biased judgments of other qualities.’ [7]
Self‐Serving Bias: We tend to blame external forces when bad things happen and give ourselves credit when good things happen.
Attentional Bias: We naturally pay attention to some things while simultaneously ignoring others, dependent on what interests us most, or what we are knowledgeable about. When planning which car to buy, a designer may pay attention to the look and feel of the exterior and interior but ignore the safety record and fuel economy, whereas a mechanic may do the opposite.
Psychology offers many further illustrations, for example:
‘Transference occurs when a person redirects some of their feelings or desires for another person to an entirely different person.
One example of transference is when you observe characteristics of your father in a new boss. You attribute fatherly feelings to this new boss. They can be good or bad feelings.
As another example, you may meet a new neighbour and immediately see a physical resemblance to a previous spouse. You then attribute mannerisms of your ex to this new person.’ [8]
The new neighbour exists independently of us, but we can only see him or her through our own subjective lens.
The external world is only partly an objective fact. No one perceives it in the same way as anyone else. We see it through the filters which make us the persons we are.
This may not at first sight seem relevant to everyday pharmacy practice. However, in various ways, each of the examples in this book demonstrate the importance of the personal perspective, and of recognising its influence on our choices.
FROM PERSON‐CENTRED PHARMACY TO PEOPLE‐CENTRED PHARMACY
Person‐centred healthcare has been described as ‘revolutionary’ [9–11] and there is no doubt that it affords the individual person maximum respect:
‘Working in a person‐centred way means working in partnership with the individual to plan for their care and support. The individual is at the centre of the care planning process and is in control of all choices and decisions made about their lives.’ [12]
Person‐centred care is certainly an advance on the mid‐twentieth‐century traditional view of healthcare:
THE TRADITIONAL VIEW: DISPASSIONATE PROFESSIONAL DELIVERS CARE OBJECTIVELY HE OR SHE IS NEITHER PERSONALLY INVOLVED NOR AFFECTED HE OR SHE WILL ATTEMPT TO MEET ONE INDIVIDUAL’S NEEDS WHATEVER HE THINKS OF THAT INDIVIDUAL’S CHOICES
Seen like this, delivering the best pharmacy service is essentially a matter of detached science, applied to help individual patients. The pharmacist will deal with the problem per se, regardless of how she perceives the surrounding circumstances and the person who has the problem.
The disease is the disease, and the best therapy is the best therapy no matter who the pharmacist is: after a heart attack most patients will be helped by low dose aspirin – this is a simple fact regardless of what the pharmacist thinks. There is merit in this point of view. But it is imbalanced. It fails to recognise the pharmacist as an equally important participant in the process. While not contradicting the traditional view, people‐centred pharmacy is different because it acknowledges that both the professional and the patient are personally involved in the decision‐making.
IN PEOPLE‐CENTRED PHARMACY THE PHARMACIST IS NOT DETACHED
A good pharmacist will apply scientific knowledge to the best of their ability. This is true of all pharmacists. However, in people‐centred pharmacy the pharmacist applies their knowledge as a person rather than an automaton.
Everyone knows from personal experience that different people see others differently. Joe may seem diligent and cautious to Anna but obsessive and selfish to Hans. Who sees the real Joe?
There is no scientific method to apply to choose between the interpretations. They are simply different personal judgements about another person.
Is it even possible to see the real Joe? How do we prove that one interpretation is true and the other false?
This is a profound question that requires constant reflection in healthcare.
Let’s say that Anna and Hans are both pharmacists faced with the same patient. As the bulk of our examples show, in some senses Anna and Hans will see the same patient; for example, if they focus solely on the medical condition. But in other senses they will not, because what they see is in part a consequence of what makes each pharmacist a person themselves.
THE MOVE TO PEOPLE‐CENTRED CARE
Some advocates of person‐centred care (PCC) have come very close to advocating people‐centred care:
‘PCC care is a sharing of power to ensure that the answer to: “What matters to you?” drives care decisions. Patients and professionals work together, within the constraints set by the care system, in a care process to achieve goals that are meaningful to the person.
The person is an individual with an identity, a history, a cultural and personal background. The patient is a secondary role the person takes on each time they interact with health care.
Likewise, professionals are persons first and take on the role of their profession second. PCC builds on the recognition of both patients and professionals as humans first.’ [13]
I have taken this perspective to its logical conclusion.
